Reconstruction Techniques After Partial Nephrectomy: Classic vs. Sutureless Approach-A Narrative Review

PURPOSE OF REVIEW

The purpose of this review is to update the information about the different types of reconstruction after partial nephrectomy, with special emphasis on the new methods of suture-free hemostasis currently available.

RECENT FINDINGS

The aim of renal reconstruction is to avoid bleeding and leakage of the collecting system, but now the renorrhaphy technique used is considered one of the modifiable determinants of renal function after surgery. In an attempt to avoid the loss of renal function implicit in classic reconstruction, new techniques have been described to control hemostasis and urinary leakage, which employ fewer suture layers, different suture materials and designs, and a wide range of commercially available hemostatic materials. Multiple suture characteristics have been studied as a potential factor influencing the renal function observed after partial nephrectomy. Single-plane suture techniques, the use of bearded sutures, and running sutures seem to be associated with less deterioration in postoperative renal function, and deep medullary sutures should be avoided to avoid affecting the arcuate arteries. Sutureless hemostasis systems could prevent the deterioration of renal function and complications derived from suturing, also reducing ischemia time and surgical time without increasing the risk of complications.

Deceased donor kidney procurement: Systematic review of the surgical technique

INTRODUCTION

Kidney procurement procedure must be carried out following a standardized technique in order to optimize kidney grafts for their subsequent implantation.

OBJECTIVES

Review of the available literature on kidney procurement procedure.

MATERIAL AND METHODS

Narrative review of the available evidence on deceased donor kidney procurement technique after a search of relevant manuscripts indexed in PubMed, EMBASE and Scielo written in English and Spanish.

RESULTS

Deceased donor kidney procurement can be divided into two groups, donation after brain death (DBD) and donation after circulatory death (DCD). Kidney procurement in DBD frequently includes other chest and/or abdominal organs, requiring multidisciplinary surgical coordination. During the harvesting procedure, the renal vascular pedicle must remain intact for subsequent implantation and reduced ischemia time.

CONCLUSIONS

Adequate execution and perfect knowledge of the technique for surgical removal and anatomy reduces the rate of graft losses associated to inadequate harvesting techniques.

Feedlot pens with greenhouse roofs improve beef cattle performance in temperate weather

Muddy pens can negatively affect welfare and performance of feedlot beef cattle. In some regions with temperate weather, plastic greenhouse covers, above the entire pens are used to fatten cattle in a clean and dry environment. The objective of this research was to investigate effects of greenhouse roofed pens on beef cattle feedlot performance in temperate weather. Data were collected from a feedlot located in Central Mexico between 2016 and 2019. The study included 1,062 closeouts of pens with 68,305 crossbred bulls fed in pens with or without a greenhouse roof. Feeding ranged from 82 to 210 d, depending on the initial weight of cattle, which ranged from 255 to 511 kg. For each pen, average daily dry matter intake (DMI, kg of dry matter intake•animal -1•d -1), average daily gain (ADG, kg•animal -1•d -1), and feed efficiency (G:F, ADG/DMI) were measured. Factorial analyses were performed to test the interaction and main effects of initial weight grouping (light, medium, and heavy), roof, and season as fixed effects, and year as a random effect. None of the 3-way interactions were significant (P > 0.51). There were no initial weight grouping × roof interactions for DMI and ADG (P > 0.31). There was (P = 0.03) an initial weight grouping × roof interaction for G:F, as pens of all initial weight groups had greater (P < 0.01) G:F in pens with greenhouse roof than its counterpart in pens without greenhouse roof, but the advantage was greater for pens with light cattle (0.178 vs. 0.166; P < 0.01). There were no initial weight grouping × season interactions for all variables (P > 0.39). There was no roof × season interaction for DMI (P = 0.47), but there were interactions for ADG and G:F (P < 0.01). The ADG was not different (P > 0.13) during summer and autumn based on the roofing system, but pens with greenhouse roofs had greater ADG during spring (1.70 vs. 1.61) and winter (1.68 vs. 1.64; P ≤ 0.01). The G:F was greater (P < 0.01) in all seasons for pens with a greenhouse roof, with the most prominent advantage during spring (0.173 vs. 0.160). There were main effects for cattle initial weight grouping and roof for all variables (P < 0.01). Season affected DMI and G:F (P < 0.01). Pens with greenhouse roofs had decreased DMI (9.70 vs. 9.86), greater ADG (1.67 vs. 1.63), and increased G:F (0.173 vs. 0.166) compared to pens without greenhouse roofs (P < 0.01). Pens with greenhouse roofs in feedlots located in temperate regions positively affect beef cattle performance.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n = 9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, p = 0.19), major complication rate (0% vs. 8.1%, p = 0.51), or transfusion rate (11.1% vs. 19%, p = 0.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR: 0.11, 95%CI 0.01-2.86; p = 0.18) nor transfusion (OR: 0.46, 95%CI 0.02-7.38; p = 0.58).

CONCLUSIONS

In our study on left RCC with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Utility of preoperative vascular embolization of renal tumors with left renal vein tumor thrombus

INTRODUCTION AND OBJECTIVES

Preoperative renal artery embolization (PRAE) for large renal masses may be performed prior to nephrectomy in order to simplify the procedure and reduce intraoperative bleeding. The objective of this work is to determine the role of PRAE on intraoperative bleeding and postoperative complications in left renal tumors with tumor thrombus limited to the left renal vein (level 0).

MATERIAL AND METHODS

Retrospective analysis to evaluate 46 patients who underwent left radical nephrectomy and thrombectomy for the treatment of renal cell carcinoma with level 0 tumor thrombus during the period 1990-2020. PRAE was limited to those cases in which surgical access to the main renal artery was presumed a priori difficult in the preoperative imaging study (n=9; 19.6%). Intraoperative bleeding was estimated based on the perioperative transfusion rate, and postoperative complications were categorized according to the Clavien-Dindo classification. The Chi-squared test was used for comparisons. A multivariate analysis was performed to identify predictors of transfusion and complications.

RESULTS

There were no significant differences in the overall complication rate (11.1% vs. 32.4%, P=.19), major complication rate (0% vs.8.1%, P=.51), or transfusion rate (11.1% vs. 19%, P=.49) between both groups (PRAE vs. non-PRAE). In the multivariate analysis, PRAE did not behave as a predictor of complications (OR:0.11, 95%CI 0.01-2.86; P=.18) nor transfusion (OR:0.46, 95%CI 0.02-7.38;P=.58).

CONCLUSIONS

In our study on left renal cell carcinomas with level 0 tumor thrombus and difficult access to the main renal artery, PRAE was not associated with increased bleeding or postoperative complications, and it did not behave as an independent predictor of these variables. Therefore, it could be used as a preoperative maneuver to facilitate vascular management in selected cases.

Advanced-stage mycosis fungoides: role of the signal transducer and activator of transcription 3, nuclear factor-κB and nuclear factor of activated T cells pathways

BACKGROUND

The malignant mechanisms that control the development of cutaneous T-cell lymphoma (CTCL) are beginning to be identified. Recent evidence suggests that disturbances in specific intracellular signalling pathways, such as RAS-mitogen-activated protein kinase, T-cell receptor (TCR)-phospholipase C gamma 1 (PLCG1)-nuclear factor of activated T cells (NFAT) and Janus kinase (JAK)-signal transducer and activator of transcription (STAT), may play an essential role in the pathogenesis of CTCL.

OBJECTIVES

To investigate the mechanisms controlling disease development and progression in mycosis fungoides (MF), the most common form of CTCL.

METHODS

We collected 100 samples that were submitted for diagnosis of, or a second opinion regarding, MF between 2001 and 2018, 80% of which were in the early clinical stages of the disease. Formalin-fixed paraffin-embedded tissues were used for histological review and to measure the expression by immunohistochemistry of surrogate markers of activation of the TCR-PLCG1-NFAT, JAK-STAT and NF-κB pathways. Folliculotropism and large-cell transformation were also examined.

RESULTS

NFAT and nuclear factor kappa B (NF-κB) markers showed a comparable activation status in early and advanced stages, while STAT3 activation was more frequent in advanced stages and was associated with large-cell transformation. Consistently with this observation, STAT3 activation occurred in parallel with MF progression in two initially MF-negative cases. A significant association of NFAT with NF-κB markers was also found, reflecting a common mechanism of activation in the two pathways. Genomic studies identified nine mutations in seven genes known to play a potential role in tumorigenesis in T-cell leukaemia/lymphoma, including PLCG1, JAK3 and STAT3, which underlies the activation of these key cell-survival pathways. A higher mutational allele frequency was detected in advanced stages.

CONCLUSIONS

Our results show that STAT3 is activated in advanced cases and is associated with large-cell transformation, while the activation of NFAT and NF-κB is maintained throughout the disease. These findings could have important diagnostic and therapeutic implications. What's already known about this topic? Mycosis fungoides is characterized by a clonal expansion of T cells in the skin. The mechanisms controlling disease development and progression are not fully understood. What does this study add? An association of the nuclear factor of activated T cells and nuclear factor kappa B pathways was found, which could reflect a common mechanism of activation. These pathways were activated in early and advanced stages at the same level. Signal transducer and activator of transcription 3 activation was associated with large-cell transformation and was more frequent in advanced stages. A genomic analysis of cutaneous T-cell lymphoma-associated genes was performed. Nine mutations were detected. What is the translational message? These results could have important implications for the treatment of MF in the near future.

[Boussignac continuous positive airway pressure device during inter-hospital transportation in infants aged less than three months]

BACKGROUND

The present study aims to evaluate the safety and effectiveness of the Boussignac continuous positive airway pressure device (CPAPB) when used during the transportation of infants under three months of age with bronchiolitis.

METHODS

Transversal analytical observational study of four years duration. Data was collected on 25 infants who needed inter-hospital transportation to the reference Paediatric Intensive Care Unit (PICU), with CPAPB and Helmet interface. The epidemiological characteristics of the transportation and evolution in the PICU were registered, as well as the cardiorespiratory gastronomic parameters prior to transfer and on arrival at the PICU.

RESULTS

The median level of continuous airway pressure (CPAP) used during the transfer was 7 cm H2O (6-7.25). No patient required endotracheal intubation during transportation, while one patient required this during the first six hours of admission in the PICU. The following cardiorespiratory parameters presented a statistically significant improvement on arrival at the PICU: modified Wood-Downes score [8.40 (2.1) vs 5.29 (1.68)], respiratory frequency [60.72 (12.73) vs 47.28 (10.31)], cardiac frequency [167.28 (22.60) vs 154.48 (24.83)] and oxygen saturation [92.08 (5.63) vs 97.64 (2.27)].

CONCLUSIONS

Application of CPAPB proved to be a safe method of respiratory support in infants under three months of age. Its use during transportation brought an improvement in cardiorespiratory parameters.

[Ectopic Warthin's tumour in nasopharynx. Revision of one clinical case]

This is a case report of a 69-year-old male patient referred to the ENT out patients with right-sided epistaxis and hipoacusis. Fibroptic examination reveals a cystic lesion at the exit of the right eustachian. A CT scan is informed as a well delimited and rounded-shaped tumour compatible with lymphoma. Excisional biopsy by a nasal rigid endoscopy is practiced and the histology result is Warthin's tumour. The nasopharynx is a rather unusual location for this type of tumours, almost exclusive in origin of major salivary glands. It's highlighted the unforeseeable histological diagnosis in this particular anatomical region, where the clinical differential diagnosis is broad and the access difficult.

Manifestaciones ORL de la displasia ectodérmica hipohidrótica

Hypohidrotic Ectodermal Dysplasia (HED) is a rare recesive genetic disease linked to chromosome X whose main characteristic is the reduction of sweat glands, leading to a deficient sweating and an increase in body temperature. In HED mainly the ectodermal structures are involved such, as epidermis and its anexes (hair and nails), although non-ectodermal tissue may also become involved. Otolaryngologicalmanifestations are related to hypoplasia of the mucous glands of the upper aerodigestive tract, as chronic infections, like rhinitis, pharyngitis, bronchitis and otitis, and also epistaxis, dysphagia, anodontia and, ozena, among others. A case of a young adult male affected with HED who is referred to the Otolaryngology Departament with a history of chronic pharyngitis and ozena, is presented and the literature reviewed.

[Prognostic factors of mortality during the episode of pneumonia due to Pneumocystis carinii in patients with HIV infection]

BACKGROUND

Despite a steady decrease in its incidence, pneumonia caused by Pneumocystis carinii (PCP) are still diagnosed, and they occur frequently in patients unaware of being infected with the human immunodeficiency virus (HIV). Since it is a disease with a high mortality risk, its early diagnosis and therapy would allow these patients to benefit from the advantages afforded Pneumocystis carinii, neumonía, infecciones oportunistas relacionadas con el sida, pronóstico.by anti-retroviral therapy.

PATIENTS AND METHODS

Retrospective study, in which all adult HIV infected patients with microbiologically demonstrated PCP diagnosed at two tertiary-level hospitals in our country between 1985 and 1996 were included. The clinical records of patients were used as information source. The relative risks (RR) of death were estimated by the multivariant logistic regression.

RESULTS

PCP was the first AIDS indicating disease in approximately 70 % of cases. Thirteen percent of patients died during the episode. Patients aged over 45 years had a death RR during the episode of 3.15 (95 % CI from 0.8 to 12.2); patients previously diagnosed of AIDS had a death RR of 3.4 (95 % CI from 1.3 to 9), and those with an alveolar-arterial oxygen gradient (pA-aO2) > 50 mmHg, a death RR of 3 (95% CI from 1.1 to 8).

CONCLUSIONS

Factors independently related to survival to the PCP episode are age below 45 years, not to have had another AIDS indicating disease, and to have a pA-aO2 below 50 mmHg at diagnosis.

[Intracranial ependymomas]

INTRODUCTION

Ependymomas are tumours derived from ependymal cells, found lining the cerebral ventricles and central canal of spinal cord. Intracranial ependymomas account for 2 6% of all neoplasms of the central nervous system and at least half present in the first two decades of life.

DEVELOPMENT

We review the epidemiological, clinical, neuropathological details, neuroradiological aspects and treatment of intracranial ependymomas.

CONCLUSIONS

Ependymomas of the posterior fossa predominate in children, while supratentorial tumours are more common in adults. This analysis of the literature further highlight that total tumour removal is the treatment of choice for intracranial ependymomas. Postoperative survival was predominantly dependent on the histological grade of malignancy, the extension of surgery and the age of the patient.

Mass spectrometric study of tricarbonyl (eta(6)-phenyl methanols) of chromium(0)

A mass spectrometric study of several tricarbonyl (eta(6)-phenyl methanols) of chromium(0) was performed. Electron ionization (EI), chemical ionization (CI) and fast atom bombardment (FAB) mass spectra were acquired for each molecule, and compared in order to establish a general fragmentation pattern. The suggested pathways were investigated and confirmed by means of constant b/e linked scans and high resolution data. In addition a Hammett-McLafferty correlation for some peaks derived from the molecular ions was accomplished.

[Cystic hemangioblastoma of the spinal bulb]

INTRODUCTION

Hemangioblastomas are histologically benign tumors that comprise 8%-12% of all posterior fossa lesions in the adult. Brain stem hemangioblastomas may be solid or cystic tumors, and surgical removal of these tumors is usually possible and is the optimal treatment. We describe a case of hemangioblastoma in the medulla oblongata diagnosed with MRI. Using microsurgery technic a total excision of this intramedullary tumor was performed.

CLINICAL CASE

A 37-year-old woman with a 3-months history of progressive dysphagia and occipital headache. Neurological examination at the time of admission revealed bilateral horizontal nystagmus, paresis of cranial nerves IX, X and XII, motor weakness of the four extremities. A MRI revealed a cystic intramedullary tumor. Using a suboccipital craniectomy the tumor was totally removed.

CONCLUSIONS

Cystic hemangioblastomas of the medulla oblongata represent a small segment in the spectrum of brain stem tumors. Surgical removal of these tumors can be accomplished successfully with a low risk of neurological injury.

[Nasal rhinosporidiosis]

Rhinosporidiosis is a granulomatous disease of uncertain mycotic origin that is characterized by polypoid lesions, predominantly of the nasal mucous membrane and conjunctiva. It is endemic to India and Sri Lanki, but occasionally occurs in other regions of the world. We report a case in Spain. The modes of infection and transmission, as well as treatment, are discussed.

[HIV infection in old age: an epidemiological and clinical study in 42 patients in the Community of Madrid]

A cross-sectional study was conducted at diagnosis of HIV infection in 42 patients aged > or = 60 years attended in two hospitals in the Madrid Community. Clinical and epidemiologic characteristics were retrospectively analyzed. Mean age was 64 years, 38 patients (90.4%) were males, and 24 (57.1%) met the AIDS criteria at diagnosis. Risk behaviour: 14 (33.3%) heterosexuals, 13 (30.9%) homosexuals, 3 (7.1%) bisexuals, 3 (7.1%) had received blood derivatives, 2 (4.7%) transfused patients, 1 (2.3%) parenteral drug abuser, 1 (2.3%) others and 5 (11.9%), unknown. In 18 (42.8%) patients there was a delay of diagnosis of 7.5 +/- 1.2 months (range: 1.5-24 months). These patients had lymphocyte counts lower than those diagnosed without delay (102 +/- 20 vs 262 +/- 67.10(9)/l, p < 0.01). Patients without AIDS criteria had a likelihood of 15.4% of progression towards AIDS at one year. The survival rate of patients with AIDS at one year was 50.1%. Patients with AIDS and diagnostic delay had a survival rate at one year lower than that in patients without diagnostic delay (30.7% vs 77.8%, p = 0.03). In summary, a predominant sexual transmission was found in our series. Delay of diagnosis entails a greater clinical and immunologic deterioration and a lower survival at one year. Early diagnosis and therapy with anti-retroviral agents might induce a longer survival in these patients.

[New contributions to the study of chromophobe-cell renal carcinoma]

OBJECTIVE

The present study describes a case of the recently discovered chromophobe cell carcinoma of the kidney. Additional findings that have not been previously reported are presented and the importance of the clinical and anatomopathological diagnosis of this tumor type is underscored.

METHODS

The tumor presented in a 72-year-old female with symptoms and signs that were not distinct from those of other more common renal tumors. She underwent a right radical nephrectomy. Histopathological, immunohistochemical and ultrastructural studies were performed and the findings were compared with those reported in the literature.

RESULTS

The foregoing studies disclosed a chromophobe cell renal carcinoma, with some findings-chiefly ultrastructural-that have not been previously described.

CONCLUSION

Chromophobe cell renal carcinoma, a tumor type that has recently been identified, is the subject of several studies that have been conducted to permit its clinical and anatomopathological characterization. The present study describes some observations which, to our knowledge, have not been previously described elsewhere.

[Predictive factors of non-compliance with anti-tuberculosis treatment in patients infected with the human immunodeficiency virus]

A study was conducted to know the rate of non-compliance of antituberculosis therapy among HIV-infected patients, the factors associated with non-compliance and the evolution of these patients. The therapy compliance in 276 tuberculous HIV infected patients diagnosed in two Madrid hospitals was analyzed. Fifty-one patients (18%) were not included in the analysis (6 died without therapy, 6 were lost and 39 died during therapy). Out of the 225 evaluable patients, 36 (16%, 95% CI, 11.6-21.6) did not comply with therapy. The only factor associated with a higher therapy non-compliance was the antecedent of drug use (20% of non-compliance; relative risk: 10, 95% CI, 1.4-71). Patients using drugs at tuberculosis diagnosis had higher risk for non-compliance (31%; RR, 3.1; 95% CI, 1.6-6.3). The incidence of tuberculosis reactivation after leaving therapy was 78.8/100 patient-years. Therapy non-compliance increased death risk associated with tuberculosis (RR, 9.8; 95% CI, 4.6-21). Programs for controlling antituberculous therapy should give priority to active drug users, as this is the group with the highest risk for non-compliance.

[Spectrum of the renal pathology in HIV infection: description of 85 autopsies and clinico-pathologic correlation]

A descriptive cross-sectional study was conducted on the prevalence and histologic characteristics of renal lesions found in the autopsies of 85 patients with HIV infection: also, a retrospective analysis of clinico-biological characteristics in 56 of these patients in order to establish the factors associated with the histological findings. A total of 85 autopsies were made from 1985 to 1993; 50 autopsies (58.8%) showed renal changes: 23 (27%) infections, 13 (15.2%) acute tubular necrosis (ATN), 6 (7%) tumors, 5 (5.8%) intersticial nephritis (IN), 5 (5.8%) nephrocalcinosis (NC), 10 (11.7%) others. In an additional study: group IIc (n = 37, study group with nephropathy) had a higher incidence in the hepatitis B surface marker (HBsAg) than in group Ic (n = 19, control group, without nephropathy) (0 vs 10, p < 0.05). The presence of disseminated mycobacteriosis in the autopsy was significantly higher in the group with nephropathy than in the group without nephropathy (11 vs 1, p < 0.05). No consistent data were observed between the clinical diagnosis of nephropathy and autopsic findings. In summary, a high incidence of nephropathy was found in the autopsies of HIV infected patients, although it was not previously suspected. Renal lesions in autopsies of HIV infected patients had a tubular-intersticial predominance over glomerular lesions. The use of potentially nephrotoxic drugs, the presence of HBsAG, and some opportunist infections apparently influenced on the development of renal lesions among these patients.

[Waldenström's macroglobulinemia, cryoglobulinemia type I and membranous glomerulonephritis]

Renal complications in Waldenström's macroglobulinemia (WM) are infrequent and are characterized by the presence of PAS positive amorphous hyaline deposits in the capillary lumen, infiltrated with lymphoplasmatic cells with PAS positive inclusions in the interstices and intratubular hyaline cylinders. Membranous glomerulonephritis may be a paraneoplastic manifestation of the lymphoproliferative processes. A 67-year-old male was diagnosed of WM, type-I cryoglobulinemia with renal insufficiency without proteinuria. Renal histological examination revealed changes characteristic of nephropathy associated to WM as well as membranous glomerulonephritis. This association has not been described previously. The coexistence of two pathogenic mechanisms with a common base, lymphoproliferative disease, may explain this association.

[Bone marrow biopsy in myeloproliferative syndromes: prognostic value of cellular quantification]

The proportion of granulocytes, erythroblasts, immature cells and megakaryocytes was evaluated when revising the bone-marrow biopsy specimens of 36 patients with myeloproliferative syndromes. These proportions were compared between themselves, a so-called Z value being thus attained; such value resulted from summing the proportion of granulocytes, megakaryocytes and immature cells and subtracting the proportion of erythroblasts. According to its value, above or below the mean, the Z figure correlates with the survival, the difference between both groups appearing as statistically significant (p = 0.02).

[Airway obstruction caused by a lymphoid polyp of the palatine tonsil]

We report a case of airway obstruction in an adult patient due to a lymphoid polyp of the palatine tonsil. We discuss some aspects of etiopathogenesis and differential diagnosis of this uncommon tumour.

Heterotopic brain tissue in the oral cavity

A most rare phenomenon of heterotopic brain in the soft palate, containing elements of choroid plexus, is presented. The principal theories regarding the pathogenesis of this malformation are presented and discussed. Its most frequent sites, the treatment to be followed, and the nomenclature to be employed in this type of lesion are also analyzed.